New England Journal of Medicine examines West Virginia's new Medicaid program

Aug 28 2006

Two perspective pieces from the New England Journal of Medicine examine West Virginia's new Medicaid program, which will allow 160,000 Medicaid beneficiaries -- many of whom are parents of children enrolled in the program -- to sign a "personal responsibility contract."

The contract states that beneficiaries agree not to miss physician appointments and use the emergency department only for emergencies.

Medicaid beneficiaries who adhere to the contract every three months will receive credits that they can use to purchase additional benefits.

The state will place Medicaid beneficiaries who fail to adhere to or decline to sign the contract in a basic coverage plan with limited benefits.

Doctors must decide whether to provide care for or report beneficiaries who fail to adhere to the contract and to participate in the administrative appeals processes for beneficiaries who might lose benefits (Kaiser Daily Health Policy Report, 8/23).

• "Personal Responsibility and Physician Responsibility: West Virginia's Medicaid Plan": According to Gene Bishop, an internist at Pennsylvania Hospital and a consultant with the Pennsylvania Health Law Project, and Amy Brodkey, clinical associate professor of psychiatry at the University of Pennsylvania School of Medicine and medical director of the behavioral health service of the Family Practice and Counseling Network, the authors, the program is unfair because it makes beneficiaries responsible for factors that may be out of their control, such as physician office hours and public transportation schedules, and holds Medicaid beneficiaries to standards not required of individuals with private insurance. The program also could place a strain on the doctor-patient relationship by requiring doctors to report noncompliance. The authors suggest that physicians take a more active role in policy discussions and speak out about how such policies will affect their practices and their patients' health (Bishop/Brodkey, NEJM, 8/24).
• "Imposing Personal Responsibility for Health": It will be "difficult to predict the effects, including those on costs, beneficiaries' health and medical practice" of West Virginia's program, according to Robert Steinbrook, a physician and national correspondent for NEJM. Steinbrook notes, however, that Medicaid beneficiaries who might benefit from some of the additional services might also be the same people who "have difficulty with compliance." Steinbrook also says that any reduction in spending the state might achieve with healthy children and adults "could be offset by the costs of administering the changes ... or by increased costs for mandatory services for patients who remain" in the basic Medicaid plan. Steinbrook calls for evaluating personal responsibility programs in controlled trials and revising or ending programs that do not improve health or reduce spending (Steinbrook, NEJM, 8/24).

Commonwealth Fund Issue Brief

"Assessing Medicare Prescription Drug Plans in Four States: Balancing Cost and Access," The Commonwealth Fund: The issue brief -- by Erika Heaton and Tanisha Carino, both of Avalere Health, and Heidi Dix, assistant secretary of health and human resources in Virginia -- examines the Medicare prescription drug benefit in California, Florida, New York and Texas -- the four states with the highest number of Medicaid beneficiaries.

The report finds variations in the number of drugs covered by different plans, in the ease with which beneficiaries can obtain drugs and in cost-sharing requirements.

The brief also finds that there are more barriers to obtaining specific drugs with lower-premium plans and that many beneficiaries might not realize their medications are not covered until after they have enrolled.

The authors suggest that CMS monitor beneficiaries' experiences to determine how well drug plans are meeting their needs (Heaton et al., "Assessing Medicare Prescription Drug Plans in Four States: Balancing Cost and Access," August 2006).